Asthma: Diagnosis and TreatmentPharmacy and Therapeutics CommitteeJune 2018

Iris Ivey, RPh DUR Clinical Pharmacist

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Objectives

Review of the societal impact of asthmaReview of hereditary and environmental factors of asthmaGoals of asthma therapyPharmalogical treatment of asthmaPatient’s role in asthma care and treatment

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Societal Impact of AsthmaAsthma is the 14th most important disorder in the world in terms of the extent

and duration of disability.Asthma is responsible for about 5,000 deaths and about 2.5 million hospitalizations or emergency department visits yearly. Asthma also results in a yearly loss of millions of school and work days. 14% of the world’s children experience asthma symptoms.8.6% of young adults (aged 18-45) experience asthma symptoms.4.5% of young adults have been diagnosed with asthma and/or are taking treatment for asthma.The burden of asthma is greatest for children aged 10-14 and the elderly aged 75-79.Black and Hispanic (Puerto Rican) populations have disproportionately higher rates in poor outcomes, hospitalizations, and deaths in the United States. The total cost is estimated to be $19 billion per year.

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Components of Asthma Care

Component 1: Assessing and Monitoring Asthma Severity and AsthmaControl.

Guide treatment options by an assessment of asthma control rather than asthma severityDetermine appropriate therapy for patients who are not already on a controller medication

Component 2: Control of Environmental Conditions that affect asthma

Component 3: Medications

Component 4: Education for a Partnership in Care

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GOALS OF ASTHMA TREATMENTReduce impairment:

Reduce symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath),Minimal need (≤2 days per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms,Few night-time awakenings (≤2 nights per month) due to asthma,Optimization of lung function,Maintenance of normal daily activities, Satisfaction with asthma care on the part of patients and families.

Reduce risk:Prevention of recurrent exacerbations and need for emergency department or hospital care,Prevention of reduced lung growth in children, and loss of lung function in adults,Optimization of pharmacotherapy with minimal or no adverse effects.

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Stepwise Approach to Asthma Treatment

Other control options

Step 1consider low dose ICS

As-needed SABA with no controller

Step 2

Regular low dose ICS + SABA as needed

Leukotriene receptor agonist (LTRA) or low dose theophylline

Step 3

Low dose ICS/LABA

med/high dose ICS + LTRA or theophylline

as needed SABA or low dose ICS/formoterol

Step 4

Medium dose ICS/LABA

add Tiotropium, or med dose ICS +LTRA or theophylline

as needed SABA or low dose ICS/formoterol

Step 5

Refer for expert investigation and add on treatment

low dose ICS, tiotropium, anti-IgE, anti-IL5

as needed SABA or low dose ICS/formoterol

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HEDIS Adherence Measure

Asthma Medication RatioThe goal of the measure is to ensure patients are on controller medications and are adherent to their controller medications.

Assesses adults and children 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

Measure to help providers assess the quality of asthma care received by their patients with persistent/chronic asthma.

AMR is a good predictor of acute asthma exacerbations

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Barriers to Asthma Medication Adherence

Forgetfulness

Cost

Education

Drug safety

Belief that the patient's asthma is not severe enough to require daily treatment

Daily life hassles

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Tips from a PharmacistMotivational Interviewing

Develop and use communication skills to enhance competence in caring for all patientsDevelop a partnership with patients in establishing treatment goals

Asthma Action PlanEncourage adherence to action plan

Asthma Education Understand the role of medicines and how to take them

Inhaler TechniqueUnderstand what triggers asthma attacks and how to avoid themRecognize early signs and symptoms of worsening asthma

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Patient Education DiscussionsAsthma Education Issues Patients Discuss with Their Health Care Providers

Patients Physiciansa?

A plan for treating asthma 53% 87%

Correct inhaler technique 63% i<, 95%

Keeping daily symptom medication diaries 23% x y 50%

Monitoring peak expiratory flow 37% 34%

Contacting patient support groups 7% 26%

Patient question: Does your doctor or other healthcare professional in his or her office discuss any of the following with, you?

Physician question: Do you regularly discuss the following with your asthma patients?

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Patient EducationController VS Rescue!

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Inhaler technique

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Conclusion

Goals of asthma therapy include:

Helping people with asthma gain and maintain control will reduce the burden of asthma in all populations.

A reduction in the number of deaths, hospitalizations, emergency room visits, missed school and work days, and limitations of activity due to asthma.

Increased medical management by delivering comprehensive care of asthma in all populations.

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Resources

http://ginasthma.org/2018-pocket-guide-for-asthma-management-and-prevention/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651005/

National Heart, Lung, and Blood Institute Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3) www.nhlbi.nih.gov/guidelines/asthma Physician Asthma Care Education (PACE): www.nhlbi.nih.gov/health/prof/lung/asthma/pace/ National Asthma Control Initiative (NACI): http://naci.nhlbi.nih.gov

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